Highlighting Habit in an Intervention for Anorexia Nervosa

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In my work at the Columbia Center for Eating Disorders, I meet with patients with anorexia nervosa who are considering joining us in our research mission and receiving treatment. Patients commonly express despair about being imprisoned by their symptoms – being unable to focus on a conversation with a friend at lunch due to reading nutrition labels on a yogurt container or cutting a sandwich into mini bite-sized pieces, feeling compelled to check their bodies or weight repeatedly, and moving, moving, moving all the time. Many of these individuals decide to take a time-out from real life to come into the inpatient program – a difficult decision that no one wants to have to make – and yet, when they arrive, even within the structure and support of the inpatient program, the calorie counting, sandwich cutting, body checking, and fidgeting or pacing sometimes continues.

Why is it that patients with anorexia nervosa find themselves “off and running” with routines of illness despite best efforts and intentions in treatment to change behaviors?

Lately, we’ve been studying if habit might play a role.

Habits are behaviors that may have begun to achieve a specific goal; with repetition, however, the behaviors (or sequences of behaviors) become increasingly automatic and set, until little or no mental effort is required to maintain them.

Habits can be incredibly useful, allowing the mind to multitask and enabling efficiency. Yet sometimes habits take hold when they are not useful.

Many behaviors that promote and maintain low weight have features of habits. For example, a person with anorexia nervosa may start out choosing to eat a low-fat diet to achieve weight loss (in this case, the rewarding outcome). Later, she may continue to select low-fat foods at every meal, even if the weight loss goal has been reached. As the disorder takes hold, and as the behaviors of illness become increasingly troublesome, cues – such as emotional states, time of day, or even something as simple as the presence of a nutrition label – remain powerful in eliciting behaviors.

From our initial research into the habit-centered hypothesis, we have evidence that patients with anorexia nervosa are using different neural circuits when making decisions about what to eat.

With these results in mind, we asked: if this disorder is even partially explained by hijacked habit learning, might this explain the difficulty patients experience in making behavior change despite their motivation to do so? We naturally wondered if habit-busting techniques could be part of the solution, so our treatment development team got to work.

To test this idea, we applied a brief behavioral intervention – Regulating Emotions and Changing Habits (REaCH) – to the treatment of anorexia nervosa.

Study Specifics

What was our approach?

The main components of REaCH were adapted from habit-reversal therapy, a behavioral approach that is well supported for trichotillomania (hair-pulling disorder) and tic disorders. In REaCH, study therapists worked with patients to strengthen awareness of the cues preceding their habits, suppress unhelpful habits, create new routines, and practice techniques to cope with the distress that arises with behavior change. The therapist and patient created a personalized list of problematic, automatic routines and then brainstormed all kinds of ways to disrupt this habit. For example, some individuals with anorexia nervosa describe a pattern of automatically and frequently checking nutrition labels at mealtime. Habit-busting this could involve entering the dining room in conversation with someone else, turning the item with a nutrition label away from the eye-line, or reaching for it with a non-dominant hand (to make the action less natural and more likely to be changed). Between sessions, the patient tried each strategy, evaluated how well it worked, and sometimes came up with a new, creative idea to test. Over several sessions, the therapist and patient honed in on the most useful strategy, talked about rewarding aspects of doing things differently, and then selected another habit to target.

How would our approach measure up?

We compared REaCH to Supportive Psychotherapy because the approaches are distinct. In Supportive Psychotherapy, the therapist and patient focused on the patient’s transition to the hospital program. Over several sessions, they discussed her motivations for inpatient treatment, the challenges of acclimating to the unit, and difficulties of meal completion and tolerating the weight gain process.

Adults with anorexia nervosa who came to our inpatient unit were offered the opportunity to participate in this study. The specific intervention they got – ReaCH or Supportive Psychotherapy – was chosen at random. Everyone received twelve sessions of their assigned intervention over four weeks.

To see if and how the treatments worked, participants completed self-report measures of habit strength, eating-disordered thoughts and attitudes, and ability to tolerate difficult emotions, and ate a meal in our research setting at the start and end of the study.

Study Results

Twenty-two women (ages 17-48) with anorexia nervosa participated in this study. Findings included:

  • The REaCH group reported significantly greater improvement in habit strength (i.e., lower habit strength) and in eating-disordered thoughts and attitudes than the Supportive Psychotherapy group.
  • Results suggest more improvement in eating for the REaCH group, though this effect was not statistically significant.
  • Treatment type did not impact self-reported ability to tolerate difficult emotions.

What did we learn from this study? What are the next steps?

This was what we would consider a small, “proof-of-concept” study. We are encouraged by the preliminary results, which suggest that the REaCH intervention did target eating disorder related habits as we had hoped. But this was a small study, which can impact our ability to adequately test all of our hypotheses. The trend suggesting better food intake after REaCH relative to Supportive Psychotherapy is encouraging, and we hope to re-evaluate this in a bigger sample in the future.

Moving forward, we are also interested in measuring the sustainability of habit change over time and testing our intervention as an add-on to treatment in outpatient settings.

To read more about the study described above, check out:

Steinglass, J.E., Glasofer, D.R., Walsh, E., Guzman, G., Peterson, C.B., Walsh, B.T., Attia, E., & Wonderlich, S.A. (2018) Targeting habits in anorexia nervosa: A proof-of-concept randomized trial. Psychological Medicine, 1-8. doi:10.1017/S003329171800020X

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  1. This is a great study, Deborah.

    Suggestion: it would be compelling to examine OCD as part of this research study to help explain/validate why the reason the habits become commonplace.

    For example, if there is success in weight loss, the patient wants to repeat that particular method over and over to ensure maintenance of the weight loss, then restrict from that point. The repetition becomes the one thing the patient can control toward achieving their ultimate goal of “perfection”.

    • Thanks for your comment, Stacey! Our group has over the years also been interested in potential shared mechanisms of illness and treatment between OCD and eating disorders, so your suggestion is well taken.

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